Isidoro Di Carlo

Increased use of percutaneous technique for totally implantable venous access devices. Is it real progress? A 27-year comprehensive review on early complications.

BackgroundFirst implantation of a totally implantable venous access device (TIVAD) was performed in 1982 with surgical technique. Since then, these devices have permitted infusion of total parenteral nutrition, antibiotics, blood products, and, above all, they have definitively changed the quality of life of patients with cancer. However, with the increase of percutaneous procedures, we have assisted with a concomitant raise of immediate postprocedural life-threatening complications. The aim of this study was to review the literature during a 27-year period, with regard to the changes of incidence of immediate complications after percutaneous or surgical cutdown for TIVAD’s implant.Materials and MethodsAn extensive search of relevant literature was carried out by using MEDLINE (PubMed) and Google Scholar. We gathered articles from 1982 to 2009 that quoted patient’s number, type of pathology, specialist involved, number of devices implanted, site and technique of implantation (surgical cutdown or percutaneous technique), and immediate complications occurrence.ResultsA total of 952 reports were screened, and finally only 45 articles addressing all inclusion criteria were used for the present study. A total of 11,430 TIVADs implanted in 11,381 patients were analyzed. Pneumothorax, hemothorax, arterial puncture, and hemoptysis developed only after percutaneous procedures. Atrial fibrillation, hematomas, and malpositioning were more frequent after percutaneous approach. The total amount of immediate complications in patients submitted to percutaneous implant was 4.5%, compared with 0.9% subsequent to cutdown technique.ConclusionsDespite the increased use of percutaneous technique for TIVADs’ implantation, surgical cutdown, because of its safety, remains the best approach to avoid possible fatal immediate complications.

External Jugular Vein Cutdown Approach, as a Useful Alternative, Supports the Choice of the Cephalic Vein for Totally Implantable Access Device Placement

BackgroundCephalic vein (CV) cut down for totally implantable venous access device (TIVAD) placement has been accepted as an alternative to the percutaneous subclavian vein approach. The aim of this retrospective study was to validate the external jugular vein (EJV) cut-down approach when the CV is not feasible.MethodsPatients receiving a TIVAD from January 1995 to December 2003 were included in this study. Age, sex, surgical technique, disease, device used, length of the procedure, and morbidity were considered.ResultsA total of 427 TIVADs were placed in 425 patients: 253 men (59.5%) and 172 women (40.5%) aged 31 to 79 years. Of 425 patients, 5 were excluded; 420 underwent a CV cut down on the first attempt, and 391 (93.1%) procedures were successful. Among the final 29 patients, 20 (68.96%) underwent a TIVAD placement through the ipsilateral EJV cut-down approach. In the remaining nine patients (31.04%), TIVAD placement was performed through the ipsilateral internal jugular vein in four cases, via the ipsilateral axillary vein in three cases, and through the ipsilateral coracobrachial vein in the other cases. No immediate postoperative complications were detected in any of the patients.ConclusionsTIVAD placement by the CV cut-down approach is safe and fast, and its success rate is very high. By avoiding the immediate complications associated with the percutaneous approach, the EJV cut down has to be considered a valid, safe, and suitable alternative when the CV is not feasible.

Hepatocellular Carcinoma: Novel Molecular Targets in Carcinogenesis for Future Therapies

Background Hepatocellular carcinoma is one of the most common and lethal malignant tumors worldwide. Over the past 15 years, the incidence of HCC has more than doubled. Due to late diagnosis and/or advanced underlying liver cirrhosis, only limited treatment options with marginal clinical benefit are available in up to 70% of patients. During the last decades, no effective conventional cytotoxic systemic therapy was available contributing to the dismal prognosis in patients with HCC. A better knowledge of molecular hepatocarcinogenesis provides today the opportunity for targeted therapy. Materials and Methods A search of the literature was made using cancer literature, the PubMed, Scopus, and Web of Science (WOS) database for the following keywords: “hepatocellular carcinoma,” “molecular hepatocarcinogenesis,” “targeted therapy,” and “immunotherapy.” Discussion and Conclusion. Treatment decisions are complex and dependent upon tumor staging, presence of portal hypertension, and the underlying degree of liver dysfunction. The knowledge of molecular hepatocarcinogenesis broadened the horizon for patients with advanced HCC. During the last years, several molecular targeted agents have been evaluated in clinical trials in advanced HCC. In the future, new therapeutic options will be represented by a blend of immunotherapy-like vaccines and T-cell modulators, supplemented by molecularly targeted inhibitors of tumor signaling pathways.

Hepatic resections using a water-cooled, high-density, monopolar device: a new technology for safer surgery.

Several techniques and devices have recently been developed in an effort to allow safer liver resections and avoid intraoperative blood loss. The aim of this study was to analyze our initial experience with hepatic resections using a new water-cooled, high-density, monopolar device—the Tissuelink Monopolar Floating Ball (Tissuelink Medical, Inc., Dover, NH)—in order to avoid bleeding during hepatic surgery. We analyzed patients who underwent hepatic surgery between January and June 2003. Sex, age, type of disease, and type of surgical procedure, in association with the duration of the surgical procedure, blood loss, use of vascular clamping of the liver, length of hospital stay, morbidity, and mortality were analyzed. Seven minor liver resections, two major liver resections, and one total cystopericystectomy were performed with the use of this new device. Average blood loss was 150 ml (range 50 to 300 ml). No vascular clamping was used with the exception of one patient. No deaths were recorded. Morbidity included ascites in one case and pleural effusion in another. In conclusion, the Tissuelink Monopolar Floating Ball permitted excellent coagulation of the cut liver surface, thus avoiding bleeding and vascular clamping. As a result, postoperative morbidity and mortality were low.

Health-related quality of life in patients with hepatocellular carcinoma after hepatic resection, transcatheter arterial chemoembolization, radiofrequency ablation or no treatment

BACKGROUND Aim of this work was to compare quality of life (QoL) of patients affected by HCC and submitted to hepatic resection (HR), transarterial chemoembolization (TACE), radiofrequency ablation (RFA), or no treatment (NT). METHODS Patients affected by HCC between 2001 and 2009 were considered for this study. Gender, diabetes, hepatitis status, Child grade, tumor size, and recurrence were analyzed. QoL was assessed before treatment and 3, 6, 12, and 24 months after, using a FACT-Hep questionnaire. P value was considered significant if <0.01 and highly significant if <0.001. RESULTS Fourteen patients (27.45%) were treated with HR, 15 patients (29.41%) underwent TACE, RFA was performed in 9 patients (17.65%), and 13 patients (25.49%) were not treated. Physical well-being, social/family well-being, emotional well-being, functional well-being and additional concerns 24 months after HR were significantly higher compared to all other treatments. CONCLUSIONS Hepatic resection provides the best QoL at 24 months. RFA provides a worse QoL compared to HR, but a higher QoL compared to TACE or NT.

Catheter fracture and cardiac migration: a rare complication of totally implantable venous devices.

Totally implantable venous device (TIVD) are widely used for the treatment of patients requiring long‐term chemotherapy, total parenteral nutrition and fluid replacement. Until today, many kinds of complications have been reported in the literature. We report an unusual case of catheter fracture as a consequence of pinchoff syndrome, and discuss the potential methods to avoid this complication and its evolution. J. Surg. Oncol. 2000;73:172–173.

Chronic hepatitis C: This and the new era of treatment

Over the last years it has started a real revolution in the treatment of chronic hepatitis C. This occurred for the availability of direct-acting antiviral agents that allow to reach sustained virologic response in approximately 90% of cases. In the near future further progress will be achieved with the use of pan-genotypic drugs with high efficacy but without side effects.

TachoSil use in abdominal surgery: a review

The success of any surgical procedure is based on adequate hemostasis. Many different biomaterial products can be used to achieve that aim. The products that can be used during surgery may be classified as topical hemostats, sealants, and adhesives. Hemostats can clot blood. Sealants can create sealing barriers. Adhesives bond tissue together. Collagen, gelatin, and cellulose are hemostat agents. TachoSil® is a development of TachoComb® and TachoComb® H. TachoComb is made with equine collagen, bovine thrombin, bovine aprotinin, and human fibrinogen. The clinical efficacy of TachoSil was shown firstly by a clinical study of hepatic surgery. In the study, TachoSil proved to be superior to argon beamer in obtaining effective and fast intraoperative hemostasis. Following the study, many applications in different fields of surgery have been reported in the literature. The use of TachoSil in open abdominal surgery and its relevant results have encouraged the use of TachoSil in laparoscopic surgery. Unfortunately, its use in laparoscopy has not become as popular as it is in open surgery, due to a lack of efficacious techniques. Immunologic reactions to compounds of TachoSil and the transmission of infectious diseases are two major risks concerning topical hemostasis. Even though the risk of severe immunologic reactions to bovine material is low, TachoSil has gradually replaced all bovine material with material of human origin and has therefore eliminated the associated risks of bovine material. TachoSil has a good satisfaction rate among surgeons and reduces both the operating time for patients and the time spent in intensive care units.

Simultaneous occurrence of adenoma, focal nodular hyperplasia, and hemangioma of the liver: Are they derived from a common origin?

Abstract  The association between hepatic hemangioma (HH) and focal nodular hyperplasia (FNH) or the association between FNH and hepatic adenoma (HA) has been reported. The authors report a case in which FNH, HH, and HA simultaneously appear in the liver. A 25‐year‐old woman was admitted to the Department of Surgery of the University of Catania (Italy), after presenting pain in the right hypocondrium. No therapy with oral contraceptives, no pregnancy and no abnormalities of the laboratory tests were found. Ultrasonography and computed tomography scans revealed four masses with the characteristics of HH, HA, FNH, and a hydatid cyst located, respectively, in segments II, IV, IV, and V of the liver. The surgical procedures performed were hemangioma and adenoma enucleation and en bloc resection of the FNH, hydatid cyst and gallbladder. No complications were recorded in the postoperative period and the patient was discharged from the hospital after 1 week. A pathological examination confirmed the preoperative diagnosis. To the best of our knowledge, the association of HH, FNH, and HA has never been reported. A common pathogenesis has clearly been demonstrated for hepatocytes and other cell types. The simultaneous presence of these three different kinds of tumor suggest that HH, FNH and HA could be the different expression of the same malformative anomaly.

WSES guidelines for management of Clostridium difficile infection in surgical patients

In the last two decades there have been dramatic changes in the epidemiology of Clostridium difficile infection (CDI), with increases in incidence and severity of disease in many countries worldwide. The incidence of CDI has also increased in surgical patients. Optimization of management of C difficile, has therefore become increasingly urgent. An international multidisciplinary panel of experts prepared evidenced-based World Society of Emergency Surgery (WSES) guidelines for management of CDI in surgical patients.